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Onychomadesis Following Hand-foot-and-mouth Disease

Cutis. 2016 May;97(5):E20-E21
May 6, 2016|Cutis
Hsiu-Hui Chiu, MD;Cheng-Che E. Lan, MD, PhD;Chieh-Shan Wu, MD;Kuang-Che Kuo, MD;Gwo-Shing Chen, MD, PhD,;MD
Author and Disclosure Information

Dr. Chiu is from the Department of Dermatology, Pingtung Christian Hospital, Taiwan. Dr. Chiu also is from and Drs. Lan, Wu, and Chen are from the Department of Dermatology, Kaohsiung Medical University Hospital, Taiwan. Drs. Chiu and Lan also are from the Department of Dermatology, Kaohsiung Municipal Ta-Tung Hospital. Drs. Lan and Chen also are from the Department of Dermatology, College of Medicine, Kaohsiung Medical University. Drs. Wu and Wei are from the Department of Dermatology, Kaohsiung Veterans General Hospital. Dr. Kuo is from the Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine.

The authors report no conflict of interest.

Correspondence: Kai-Che Wei, MD, 386 Ta-Chung 1st Rd, Kaohsiung, Taiwan 81362, ROC (kaijhe@gmail.com).

Practice Points

  • Onychomadesis is a late complication of hand-foot-and-mouth disease (HFMD) with a latency period of 1 to 2 months.
  • Although the mechanism between onychomadesis and HFMD is still unclear, we propose that it is caused by the viral infection itself rather than severe systemic disease.

Although there is a definite relationship between HFMD and onychomadesis, the mechanism is still unclear. Some authors claim that nail matrix arrest is caused by high fever10; however, we found that 40% (2/5)1 to 63% (10/16)4 of reported cases did not have a fever. Additionally, only 1 of our patients had fever. Therefore high fever–induced nail matrix arrest is not a reasonable explanation. Davia et al5 observed no relationship between onychomadesis and the severity of HFMD. In addition, no serious complications of HFMD were mentioned in prior reports.

We propose that HFMD-related onychomadesis is caused by the viral infection itself, rather than by severe systemic disease.1-5,7 Certain viral strains associated with HFMD can induce arrest of nail matrix activity. Osterback et al7 detected CV A6 in shed nail fragments and suggested that virus replication damaged the nail matrix and resulted in temporary nail dystrophy. This hypothesis can explain that only some nails, not all, were involved. In our cases, we noted an incomplete and slanted cleft on the thumbnail (Figure 2). We also found that incomplete onychomadesis appeared in the clinical photograph from a prior report.5 The slanted cleft in our case may be caused by secondary external force after original incomplete onychomadesis or a different rate of nail regrowth because of different intensity of nail matrix damage. The phenomenon of incomplete onychomadesis in the same nail further suggests the mechanism of onychomadesis following HFMD is localized nail matrix damage.

In conclusion, we report 2 cases of onychomadesis associated with HFMD. Our report highlights that there is no racial difference in post-HFMD onychomadesis. These cases highlight that HFMD is an important cause of onychomadesis, especially in children. We suggest that certain viral strains associated with HFMD may specifically arrest nail matrix growth activity, regardless of fever or disease severity.

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